Meeting Reviews
SPA Session 1 - Perioperative Data and Decision Support: Can We Improve Outcomes by Improving Our Processes?
By Zulfiqar Ahmed, MD, FAAP
Anesthesia Associates of Ann Arbor
The third lecture of the day was delivered by Brian S. Rothman, MD, chief information officer at Vanderbilt University (Nashville, TN) and associate professor of Anesthesiology and associate professor of Biomedical Informatics and Surgery.
Dr. Rothman tackled a very technical subject with skill and ease. The objectives of his talk were as follows:
- Identify and describe complexities surrounding data use to improve outcomes and advanced development concepts that can lead to effective, real-time decision support.
- Distinguish between guidelines and clinical decision supports that may improve care processes and patient outcomes.
- Translate these concepts to enhanced recovery pathways within a Perioperative Surgical Home to improve care processes and patient outcomes.
Dr. Rothman’s talk may be summarized with a few basic points:
- There are complexities around data.
- Data can improve outcomes and provide real time clinical support.
- Data helps develop guidelines and clinical support.
- Data improves situational awareness and ability to detect, diagnose and predict.
- We need automated and contemporaneous data flow.
- We are clinically competent, professional, empathic and hard working. Now we NEED data.
- The results we create will be visible to the highest levels of administration and will include cost containment, freed hospital beds and improved outcomes.
Dr. Rothman started his talk by mentioning that over time, anesthesia practice has evolved from pent/sux/tube to an art form. Patients are more complex, and our care plan options have multiplied. We have many more relationships to maintain which has lead to higher variability. The significant gaps between knowledge and practice have led to unnecessary, incomplete and ineffective care. Larger dollar amounts do not necessarily lead to better care. The cost of medical care is rising faster then GDP which is unsustainable. Insurance companies and hospitals are committed to bending this growth curve. In 2009, the Affordable Care Act declared the triple aim of meaningful use to be:
- Improve population health
- Enhance patient experience and outcomes
- Reduce cost per capita
In 2016, MACRA aimed at the following targets:
- Shift from incentivizing process to outcomes
- Increased electronic health record (EHR) adoption (smaller practices not so much)
- Population management (no outcomes shown yet)
These targets are leading the way to standardized care, protocols, guidelines and standards.
In order to create data systems to meet these targets, we need robust information systems to tell us what works and what does not. Advanced design concepts will create the base of such systems and must include transparency, active information, integration and augmented vigilance. Data created will lead to increased situational awareness.
Situational awareness is defined as, “The perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.” We must use the information to detect, diagnose and predict the health status of our patients. Rapid response teams arrive too late. Physiologic changes begin six to eight hours prior to clinically visible adverse events. We must aim identify these changes earlier to prevent patient harm.
An example of data transparency is the OR electronic board displaying current patient status including location, alerts, allergies and age among other information pieces. Data integration brings information from multiple modalities together and facilitates higher level decision-making. Augmented vigilance leads to active delivery of real time, relevant information to the appropriate location and personnel at the appropriate time. The result is clinical decision support (CDS) which can recommend possible actions based on integrated data and best practices leading to improved performance and outcomes.
One important deficiency of EHRs at present is “Gap Analysis”. In such gaps, data is collected, but not entered (contemporaneous charting) or entered after a decision point has arrived. An example is availability of risk factors for postoperative nausea and vomiting after an anesthetic has started or once the patient is in the recovery room.
In conclusion, Dr. Rothman stated that we cannot allow ourselves to be commoditized. Our excellent clinical skills, professionalism and medical knowledge get us a seat at the table; what hurts us is our safety record, effectiveness and technological high ground. Drastic action may be required, as we need more than caring, professionalism, ownership, and vigilance.
Improved technology and medications can position anesthesiologists to lead care throughout the hospital. We need to innovate the collection, translation and application of data to improve patient safety and outcomes. Resistance is futile and will only result in someone else writing our history for us. We need to move beyond the operating room and help create standardized, coordinated care that reduces length of stay, complications and improves patient outcomes.
